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Dr. Jacquelyn Paykel
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Home>>Sexual Health>>Sexual
Pain
Sexual Health

Vulvodynia, simply put, is chronic vulvar pain without an identifiable cause. The location, constancy
and severity of the pain vary among sufferers. Some women experience pain in only one area of the
vulva, while others experience pain in multiple areas. The most commonly reported symptom is
burning, but women’s descriptions of the pain vary. One woman reported her pain felt like “acid
being poured on my skin,” while another described it as “constant knife-like pain.”

Vulvodynia is defined as sensations of burning, rawness, stinging, stabbing, tearing, aching, or
irritation that have been present for at least six months, and are not caused by any specific cause –
no infection, skin disease, or specific nerve abnormality. Although there is no cure for vulvodynia,
most women respond well to therapy and symptoms can be controlled. Treatment is slow, and
often several different therapies have to be tried. Occasionally, vulvodynia simply goes away.

Vulvodynia most likely is caused by a combination of nerve abnormality (neuritis, neuralgia), pelvic
floor muscle weakness and irritability, irritation from previous treatments and overwashing, and
anxiety/depression. Several kinds of nerve abnormalities probably produce vulvodynia, but there is
little research investigating this. Some patients have more nerve endings in the skin than other
women, perhaps making the area more sensitive than normal. Another form of nerve pain called
“reflex sympathetic dystrophy” or “regional complex pain syndrome”. In this kind of discomfort, pain
signals from an injury (and the injury may be minor, such as a severe yeast infection, or major,
such as surgery) continues after the cause of the injury resolves. Another form of nerve pain occurs
when the pudenal nerve is injured, as may occur with childbirth or surgery. A pinched nerve from a
bad disc in the back may be responsible in some patients. Also, many patients may have
vulvodynia as a result of the brain’s interpretation of nerve impulses, so that normally painless
experiences are perceived as painful (sexual activity, tight clothing). These women often have other
pain syndromes, such as headaches, irritable bowel syndrome, interstitial cystitis, fibromyalgia,
temporomandibular joint syndrome, etc. Vulvodynia caused by all of these forms of nerve
abnormality have three features in common: First, the physical examination is usually normal
except for some patients who may have some redness, swelling, or thinning of the skin. Second,
there is no easy, specific test to prove these diagnoses. Third, medications for neuropathic pain,
such as amitriptyline and desipramine and attention to the pelvic floor muscles generally improve
vulvar burning and irritation in most people.

Most skin diseases and infections of the vagina and vulva produce itching rather than burning and
pain with sexual activity. However, infection can be eliminated as a cause of vulvar burning and pain
by a negative culture (or burning that continues after successful elimination of the infection). And,
skin disease is visible to the examiner. Redness and a feeling of swelling are common in
vulvodynia and do not signify skin disease or infection. Occasionally, skin disease in the vagina
(desquamative inflammatory vaginitis and lichen planus) can be sneaky causes of burning, but an
examination of vaginal fluid that appears normal under the microscope eliminates these diseases
as possibilities.

Vulvodynia is not associated with cancer, sexually transmitted disease, or any kind of infection that
is passed back and forth between sexual partners. There is no relationship of vulvodynia to AIDS.
Vulvodynia does not affect fertility or the ability to carry a pregnancy to term and have a normal
delivery. Vulvodynia is not an early sign of any disease that affects overall health. There is no good
evidence that vulvodynia is a psychosomatic disease, but it is well known that vulvodynia causes
tremendous emotional stress, and stress worsens the symptoms of any disease. Also, the anxiety
and depression that longstanding genital pain produces, the psychological injury to a woman’s self
esteem and her sexual identity, and the damage to the relationship with a sexual partner can be
devastating.

The management of vulvodynia addresses the several different causes of vulvodynia, so treatment
involves several different therapies at the same time.

First, you should stop all things that may be irritating the skin. Avoid soap, panty liners, creams for
infections, any medications with benzocaine or diphenhydramine to numb the skin, and most
commercial vaginal lubricants (KY Jelly).

Second, lidocaine jelly 2% is a mild and safe numbing jelly which can be used both any time you
are burning, and for 15-20 minutes before sexual activity.

Third, there are medications for neuropathic pain. These include medications that were originally
developed for depression, but have been found to have specific benefits for neuropathic pain.
These are amitriptyline (Elavil), desipramine, venlafaxine (Effexor), and duloxetine (Cymbalta).
Other well known antidepressants including fluoxetine (Prozac), paroxetine (Paxil), bupropion
(Wellbutrin), (citalopram) Celexa, etc, are useful antidepressants, but have no independent effects
on pain. Medications developed for seizures are sometimes useful as well. Those most often used
are gabapentin (Neurontin) and pregabalin (Lyrica).

Fourth, most women benefit from therapy to strengthen pelvic floor muscles. This can be done with
physical therapy or with a fairly well-studied (but not widely available) regimen of home exercises
with the use of surface electromyography as a biofeedback tool.

Fifth, there are a number of topical therapies used in some women, depending upon many factors
including the location of pain, age, and response to other treatments. These include the regular
nighttime use of lidocaine ointment 5%, estrogen, nitroglycerin, and amitriptyline/baclofen
combination ointment.

Sixth, a few clinicians have used more experimental treatments, including Botox (botulinum toxin),
acupuncture, and hypnosis. A low oxalate diet with calcium citrate with meals is occasionally used.

Seventh, women with pain absolutely localized to the opening of the vagina (vestibulodynia, or
vestibulitis, subset of vulvodynia) can be treated with surgery.

Eighth, BUT NOT LAST, is counseling and sex therapy. Even though the cause of vulvodynia is not
psychological, the psychological repercussions can be devastating. Most women experience
feelings of depression, anger, anxiety, guilt, loss of self esteem, loss of libido and loss of feelings
of femininity and sexuality. Their partners are often experiencing many of the same emotions. As
women avoid sexual intimacy, many avoid other kinds of physical contact because of fear that
touching of any kind might progress to painful or unwanted sexual activity. Soon, loss of intimacy,
both physical and emotional, occurs. Because pain with intercourse, and sometimes a complete
inability to have intercourse, is a very private and intimate matter that can be difficult to discuss,
women generally do not discuss this with other family and friends. Also, the pain sometimes
interferes with choice of clothing, diet, and activities such as exercise, sitting for long periods, etc,
impacting all areas of life.

Recovery from vulvodynia requires not only the medical treatments above, but also attention to your
– and your partner’s – psychological health is crucial.

Additional information and regular newsletters can be obtained from joining the National
Vulvodynia Association.  

National Vulvodynia Association

Vestibulodynia, AKA vestibulitis or vulvar vestibulitis, is form of vulvodynia limited to the vestibule.  
The vestibule is the tissue at the opening of the vagina inside the labia minora distal to the
hymenal ring of the vaginal vault.  The pain can be either provoked or unprovoked.  A survey in a
community settings in the United Kingdom shows a prevalence of 2.8-9.3%. The erythema
localized to the orifices of the vestibular glands in the absence of an infective, inflammatory, or
neoplastic cause.  The burning nature of the pain is typical of dysaesthesia, and many patients go
on to develop more persistent and generalized vulvar pain that would be compatible with
dysaesthetic vulvodynia, a condition classically found in older women. The pain of vulvar vestibulitis
should be distinguished from vulvar pruritus, which has different causes.






















The cause of the condition is unknown, attempts to identify an infective cause have been
unsuccessful, and no characteristic histological findings are known.  The subtlety of the physical
findings may lead some clinicians to say that “there is nothing wrong” and attribute the symptoms
to a psychosomatic disorder.

Vulvar vestibulitis is poorly recognized by primary care doctors and some gynecologists, and this
may lead to patients repeatedly seeking a diagnosis from a variety of clinicians over a long period
of time.  A common misdiagnosis is recurrent thrush. Such patients will explain that they have tried
all the currently available preparations against candidiasis, without relief of symptoms. Once the
condition is recognized, the patient is best referred to a specialist vulvar clinic. Since the cause of
the condition is poorly understood, management is largely pragmatic and several models of care
exist. The evidence base for treatment remains poor, but a number of studies are underway.

Establishing the diagnosis and offering the patients a sympathetic ear is an important first step.
Patients are reassured by the fact that the condition is not psychosomatic in origin and that anxiety,
low mood, and reduced pleasurable sensations with sexual arousal are common byproducts of
chronic pain that has become associated with sex. No consistent evidence exists to date to show
that women with vulvar vestibulitis have an increased background rate of psychological disorders.  
However, the chronicity and severity of the symptoms often leads to secondary effects on
psychological wellbeing and self esteem. This may lead to secondary sexual dysfunction in the
patient or her partner, which in turn can exacerbate psychological distress, emotional
disequilibrium, low self esteem, and reduced sexual and social functioning.  All of these can
become maintaining factors in the condition.

Advice about vulvar hygiene practices is required, and patients should be advised to avoid soaps,
shower gels, and similar products, and to wash with aqueous cream or emulsifying ointment.  
Topical local anaesthetics such as lidocaine ointment are often helpful. Topical steroid ointments
and creams, estrogen creams, and topical ketoconazole have been used in some centres, and
anecdotal data support their use in some patients. A popular treatment in the United States and
Canada is the use of a diet low in oxalates. This was described in a single case report,8 but, in the
absence of better evidence, it may perhaps be offered to some patients who prefer a non-
medicalized approach to treatment.  Many patients turn to complementary therapies.

Glazer et al have proposed that the condition is caused by a dysfunction of the pelvic floor muscles
and have published impressive results for a biofeedback technique.  Many patients do have pelvic
floor dysfunction, but in some cases this seems to be secondary to the pain. Low dose
amitriptyline is the treatment of choice for dysaesthetic vulvodynia and may be useful in some
patients, particularly when the pain is not restricted to attempted vaginal penetration (e.g. sitting,
wearing tight clothing, walking).  

In North America, vestibulectomy, a procedure that involves excision of all or part of the vestibule,
has been a popular treatment. Bergeron et al have reviewed 20 published case series and note
that impressive results have been obtained, but the lack of controlled studies or long term follow up
throws considerable doubt on the validity of the conclusions. In the United Kingdom, this procedure
is rarely used.

Whatever therapeutic approach is adopted, the psychological, interpersonal, sexual, and social
consequences of the condition need to be assessed. Every clinician managing patients with the
condition should have access to a psychologist or psychotherapist with experience of managing
sexual dysfunctions in individuals and couples. Many patients find that support from other patients
may be helpful. In the United States, the
National Vulvodynia Association (www.nva.com) provides a
useful handbook for patients as does the UK Vulval Pain Society (www.vul-pain.dircon.co.uk) in the
United Kingdom.
Generalized Vulvodynia